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Also Human, Caroline Elton

Full Title:: Also Human

Category:: books

Mental health issues is still a real problem in the medical profession.

Inverse Care Law, a term coined by Julian Tudor-Hart — Those who most need care end up receiving the least. In this situation, it is the vulnerable medical students being offered the least support.

Sleep experts advise we should avoid changes of day-to-day differentiation as to when we go to sleep and gets up. This related to 12 Rules for Life about predictability and stability of our days.

Often working-hour restrictions exist on paper rather than in reality. In fact, reducing work hours hasn't solved the problem of fatigue, depression, and burnout among doctors.

Exhaustion influences our adult capacity for empathy.

Strange Situation Experiment: assess differences in how infants of one to two years of age were attached to their parents.

One, infants who were "securely" attached to their mothers readily explored their new surroundings when their mother was present, showed anxiety in the stranger’s presence, were distressed by their mother’s brief absence, and rapidly sought contact and were quickly reassured once the mother returned. About 60 percent of infants fell into this group.

Two, "insecurely" attached.

Avoidant type: less upset at separation, might not seek contact with the mother on her return, and might not prefer the mother to the stranger.

Resistant type: showed limited play initially, became highly distressed by the separation, and did not easily settle once the mother reappeared.

Disorganized type: first seeking contact from the mother on her return, but then, once they were close to the mother, becoming extremely fearful.

Our early attachment experience not only influences how we respond when we are recipients of care, but is also implicited in our capacity to give care to others.

Relevant Notes Jeffrey Rachmat said once, we see things as we are, not as what they are.

Defensive strategy

The avoidant response will be elicited when we want to reduce personal exposure to experiences at work that we find aversive. This may seem unhelpful from your team's perspective, but psychologically, it makes sense.

Intellectualization: concentrating on factual, intellectual bits of a situation while ignoring the possibility that it could have any impact on one's feelings.

Suppression: conscious decision to delay paying attention to one's feelings in order to cope with present reality. For example, we have to suppress our emotion all the time when they deliver a painful or unpleasant treatment to a patient.

Repression: difficult emotions are pushed out of the conscious mind entirely. This happens when doctors become so emotionally overloaded by different aspects of their work that they stop feeling anything at all.

A recent systematic review concluded that nine out of eleven studies of medical students, and six out of seven studies of medical residents, reported a consistent decline in empathy as training progressed. Some of the reasons given for this finding include sleep deprivation, excessive workload, mistreatment by superiors, and lack of positive role models. In other words, the environment in which doctors work has a significant impact on their capacity to respond empathically to patients.

The doctor needs the capacity to imagine the physical or psychological pain that the patient is experiencing, but mustn’t be overwhelmed by the patient’s suffering.

it’s not having feelings that cause problems for doctors but not being able to regulate these feelings.

What is a Schwartz Round? Basically, it’s an hour-long opportunity for staff from across the hospital—both clinical and nonclinical—to get together to discuss the difficult emotional and ethical issues that arise in their day-to-day work. Or put differently, Schwartz Rounds provide an opportunity for staff to discuss the human dimensions of care. Topics include working with a difficult patient or family, medical mistakes, breakdowns in communication, bigotry surrounding obesity, complementary and alternative therapy, spirituality.

Palliative medicine can lead to an exceptional form of patient care; this is because palliative care physicians can’t resort to a form of clinical omnipotence and hold out the promise of a cure to their patients.

It’s not easy to listen to patients’ stories—to hear about the physical and psychological pain that they have experienced, but don't shy away.

Some doctors had to give up work in order to live because their commitment to their patients made them ill. Why? Maybe because there is an unconscious motivation to heal a sick or dead family members. The choice of work brings not only the opportunity for reparation and healing, but also the repeat of experience of failing the incurable, which, in turn, further feeds the associated emotional drive to work even harder. The cycle of death.

A shift from illness to well-being. For example, if you are an oncologist who has an interest in mindfulness meditation as a way to manage distress and painful symptoms, you might retire and focus on being a mindfulness teacher. Offer sessions to health-care staff, as opposed to working directly with patients.

This might be a way to see Opus Nuclei. Shift my interest in high-quality, ethical, health management, public health, neuroscience, from directly working with patients to work with doctors.

Another example is Dr. Pukovisa's account on Iman & Neurosains. I should be working on Opus Nuclei to work on a similar purpose. Targeting healthcare staffs, with neuroscience-backed strategies, intended to create a balanced and meaningful life.

“Why do you have to be at crisis point before there is any flexibility in the system?” she asked. I didn’t have a good answer. But I saw the irony in her question: doctors tell their patients that prevention is better than cure, yet a preventative ethos is frequently absent in medical training.

Wounded healer

A doctor's capacity for healing stems from their own suffering. Plato said in Republic: The most skilful physicians are those who, from their youth upwards, have combined with the knowledge of their art the greatest experience of disease… and should have had all manner of diseases in their own person. Quotes

Carl Jung: through the experience of personal suffering, the healer can acquire deep wisdom that they can then use for the benefit of their patients. But Jung was also aware that there was always the potential that such healers could overidentify with patients, feeling their pain too deeply, reawakening wounds of their own.

When doctors are dissatisfied at work, they tend to have more dissatisfied patients. And the patients of more dissatisfied doctors are less likely to stick to the treatment plans that they have been prescribed. Dissatisfaction is contagious.

The most common reason to choose a particular specialty:

Role models

Prior experience

Work-life balance

Newly qualified doctors are less willing to devote their entire lives to their patients, at the expense of their own families. The issues of work-life balance has a much more impact on the specialties that doctors choose to follow than it did in the past.

This is particularly true in my situation. I felt pressured to cash in more work hours as the system was not up-to-date with how young doctors operate. So where do I find consolation?

Test my assumption about the length of postgraduate training, the possibility of minimizing evening or weekend commitments, and the position of part-timers.

Not everyone gets married at the age of thirty-one. But there are set points in medical training when people are expected to choose their specialty. The idea of taking extra time over this decision is often poorly received. And trainees are frightened to ask.

Specialty decisions are sedimentary: layer upon layer of personal and family influences, the chance factors of who one encounters, the role models who inspire one or turn one away from a specialty for life. And as with rock formation, these layers build up over a long period of time.

Specialty decisions depend on how we ‘polish’ our CV instead of allowing our curiosity to guide our decision. Scientific endeavor, especially in a highly cerebral, high-pressure field like medicine, requires one to stay committed to the journey. Yet what is appreciated is a completely different thing.

Some doctors may not psychological support in the task of specialty task, but some need it. The obscurity of the information needs to be reframed. There must be an ongoing discussion about specialty choice in particular and the emotional demands of those specialties in general.

Rationality has its limits — if we really want to help people make better career decisions, we need to encourage them to think about, and inhabit, the feelings associated with their day-to-day experiences at work.

If you want to understand a virus, ask a virologist. If you want to know how viral infections spread throughout a population, ask an epidemiologist. And if you want to know how the professional culture of medicine allows the advancement of a doctor's career, you need to primarily close your eyes and pray you got the right circumstances. And oh, you need to have an awful lot of money.

Medicine is not an accommodating profession when it comes to supporting doctors with child care (or indeed any other caring) responsibilities.

Part-time doctors are less stressed and more satisfied at work.

Parenting “Siblings never have the same parents”.

Doctors can be pulled in two directions simultaneously: wanting to remove themselves from the burden of clinical responsibility yet not wanting to feel disappointed in themselves, or be a disappointment to their families.

There’s an astonishing gap between, on the one hand, advances in medical practice and, on the other, our understanding of the psychological demands of medical work. It’s almost as if the psyche has been surgically excised from our conception of what it means to be a doctor. In fact, this psychic excision underpins all the stories in this book.

We regularly require doctors to carry out extraordinarily distressing tasks with inadequate attention given to their psychological well-being. Then we blame doctors when their psychological defenses kick in and they respond to patients or relatives with a lack of empathy. Quotes

Even leaving the profession can be psychologically fraught. When doctors feel that they have been pushed to the edge, they frequently find themselves paralyzed between equal, but opposing, forces. On the one hand, there is an enormous desire to leave medicine to escape the psychological pressures of the work. On the other, there is terror that they might feel like a failure, that they have let other people down, or that they may later wish they had stayed put. Quotes

Taken together, doctors’ psychological needs are denied, ignored, not thought about. Unmet. A systemic “psycholectomy” has been performed on the profession as a whole. Quotes

To Create At secondary school I was taught the first law of thermodynamics. This law states that the energy within a system cannot be created or destroyed; it can only be transformed from one form to another. It strikes me that this basic law of physics has a psychic parallel. Perhaps it should be known as the first law of human dynamics? And just as the physical law demonstrates that the energy in a system cannot change but can only be transferred, the psychic law reminds us that a person’s ability to carry out emotional work—to care for somebody else in distress—critically depends upon the quality of care that that person has themself received. It’s almost as if the potential for giving care to others rests on a form of “caring capital” that a person has accrued in the past. And currently. If a person feels uncared for, emotionally depleted, they will struggle (in some way or other) to carry the emotional burden of another person’s suffering. They will struggle to care.

Doctor-patient relationship The extrapolation of parent-child relationship psychoanalysis to doctor-patient relationship. Not all parents love their child, so do doctors. But the reasons? Not always bad behavior. It may be because of fear of making significant mistakes, time pressures, uncertainty about diagnosis or treatment plans, fear of being the subject of a complaint, exhaustion caused by working through the night, hunger and thirst through working a whole shift without a break.

In the 1950s pediatrician and psychoanalyst Donald Winnicott wrote, “There is no such thing as a baby.… A baby cannot exist alone, but is essentially part of a relationship.” I don’t imagine that Winnicott would have been a proponent of “infant-centered care.” He understood that the relationship between parent and child was all important. Winnicott also recognized that the feelings that parents have for their children aren’t always nice. In a classic paper, he lists eighteen reasons why a mother may, at times, experience hateful feelings toward her baby. These include: He is ruthless, treats her as scum, an unpaid servant, a slave. His excited love is cupboard love, so that having got what he wants he throws her away like orange peel. He is suspicious, refuses her good food, and makes her doubt herself, but eats well with his aunt. After an awful morning with him she goes out, and he smiles at a stranger, who says: “Isn’t he sweet?”

Winnicott died in 1971. But if he were alive today, I wonder what reasons he would intuitively cite for doctors sometimes resenting, or even hating, their patients. Perhaps his list would include: Fear of making a significant mistake. Time pressures; too many patients to see in too short a time. Uncertainty about the diagnosis or treatment plan. Professional impotence when the patient’s illness can’t be cured. Patients’ unrealistic expectations about what modern medicine can achieve. Patients challenging one’s professional knowledge. Fear of being the subject of a complaint or a legal claim. Exhaustion caused by working through the night. Hunger and thirst through working a whole shift without a break. Being on the receiving end of derogatory comments from patients. Disgust at physical decay or deformity. Fear of contagion. Contempt at injuries caused by the patient’s own behavior. Having to work in a part of the country where one is separated from family and friends. Missing out on a special family celebration because one has to work. And above all else, the reason why patients have always had, and will always have, the potential to evoke difficult feelings in the doctor is that inevitably they remind doctors that they, and those they love, are mortal.

What if doctor's emotional well-being was accorded the same priority as the control of infection?

Just imagine, for a second, if the emotional well-being of the medical workforce (and the health-care workforce more generally) was accorded the same priority as the control of infection. Parity between the infective and the affective, in other words. In Lister’s time, 45 percent of patients died of infection post-amputation. Today some reports suggest that over 50 percent of doctors experience burnout. Given this level of burnout (and of depression and suicide) it would be hard to argue that we don’t have a significant public health crisis on our hands. Is the comparison really so absurd?

The culture of medicine as a whole, with its reluctance to adopt an evidence-based approach to Medical Education and its tendency to disavow any signs of vulnerability on the part of the doctor and to lay blame at the foot of the individual, is the glue loosely holding the system together.

Opus Nuclei It is a rare example of doctors using their clinical knowledge to benefit not only their patients but also other clinicians.

Resilience is always contextual, Balme, E., et al., “Doctors Need to Be Supported, Not Trained in Resilience,” BMJ Careers (2015).

Also Human, Caroline Elton